- See:
Tibia Fracture Menu and
Gustilo Classification:
- Discussion:
- is frx in which there has been extensive stripping of soft tissues and periosteum from bone & where devitalization or loss of soft tissues
usually requires plastic reconstructive procedures for closure;
- extensive soft tissue loss with periosteal stripping and sig. wound contamination;
- segmental defects measuring, on average, 10 cm were managed by:
- Initial Treatment and Timing of Surgery:
-
preoperative antibiotics;
- therapeutic doses of
ancef and
tobramycin for 48 hrs are appropriate;
- despite the added cost, tobramycin is more effective against
pseudomons and has a lower incidence prevalence of nephrotoxicity;
- note that the most frequently identified organisms in open tibial fractures are
Staph aureus and nocosomial organisms;
-
tetanus prophylaxis if appropriate;
- references:
-
Outcomes in open tibia fractures: relationship between delay in treatment and infection.
-
Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
-
Efficacy of cultures in the management of open fractures.
- Soft Tissue Defects:
-
initial wound care:
-
pressure irrigation:
-
debridement and wound closure:
- consider debriding the wound with a separate set of surgical instruments / drapes
- in most cases, the surgeon will close surgical incisions made during the case but to leave the traumatic wound open;
- leaving the wound open maximizes drainage and wound tension (which is frequently present w/ primary closure);
- at 2nd look debridement (at 48-36 hrs), the edema will have diminished and the wound can be closed w/ less tension;
- references:
-
Primary or delayed closure for open tibial fractures.
-
Timing of closure of open fractures.
-
wound dressings: (see
wound VAC);
-ref:
The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.
-
antibiotic bead pouch:
- as noted by Keating et al 1996, bead pouches help reduce the infection rate in open tibia frx from 16% to 4%;
- add 2.4 gm of tobramycin per cement package, and fashion small beads attached to a O silk suture;
- counting the beads and adding methylene blue helps ensure that none of the beads will be left behind at removal;
- a small drain is left adjacent to the beads and the wound is sealed w/ Opsite;
- references:
-
Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch Reduce the Deep Infection Rate?
JF Keating et al. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303.
-
soft tissue coverage for tibial defects
- note that if a external fixator is being considered, it should be placed in a way so as not to interfere w/ flap
application (eg a medially placed external fixator might interfere w/ a medial
gastrocnemius flap);
- references:
-
The Timing of Flap Coverage, Bone-Grafting, and Intramedullary Nailing in Patients Who Have a Fracture of the Tibial Shaft With Extensive Soft-Tissue Injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
-
Early microsurgical reconstruction of complex trauma of the extremities.
-
Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results.
-
The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.
- Fracture Management:
- external fixation:
- some prefer the external fixator, adding limited internal fixation when required to improve joint surface congruity;
- w/ an open frx, external fixation should include the foot to prevent soft tissue motion over the fracture;
- exchange IM nailing may be preferable once soft tissue reconstructive surgery has been performed;
- in the study by Webb et al - JBJS 2007, the authors determined that:
- patients treated with an ex fix had more surgical procedures, took longer to achieve full wt-bearing status, and had more infections and
nonunions (compared to IM nailing group);
- worst functional results were found in patients treated with ex fix and muscle flap (had worst outcomes than BKA)
- references:
- Open grade III “floating ankle” injuries: a report of eight cases with review of literature
- Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures
- intramedullary nailing
- references:
- Reamed nailing of Gustilo grade-IIIB tibial fractures.
- Open tibial fractures: faster union after unreamed nailing than external fixation.
- Emergency management of type IIIB open tibial fractures.
- Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures.
- Local or free muscle flaps and unreamed interlocked nails for open tibial fractures.
- Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking IM nails and half-pin external fixators.
- Nonreamed locking intramedullary nailing for open fractures of the tibia.
- Reamed interlocking intramedullary nailing of open fractures of the tibia.
- Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study.
- Contaminated fractures of the tibia: a comparison of treatment modalities in an animal model.
- The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.
- soft tissue management:
- filling of osseous defect w/ ATB-impregnated polymethylmethacrylate beads & coverage of soft-tissue defect by local myoplasty or free muscle transfer;
- by definition soft tissue coverage is usually required;
- bone grafting:
- elevation of the flap after about four to six weeks and packing of the osseous defect with large amounts of autogenous
cancellous bone graft from the iliac crest;
Open type IIIB and IIIC fractures treated by an orthopaedic microsurgical team.
Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures.
Classification of type III (severe) open fractures relative to treatment and results.
Severe open fractures of the tibia
Severe open tibial fractures: a study protocol.
Treatment of grade IIIB open tibial fractures. P. Tornetta et al. JBJS. Vol 76-B. p 13-19. 1994.
The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.
Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures.
